The BUPA ‘Decision Engine’: An Integrated Case Based Reasoning System at Work in the Private Medical Insurance Industry.
The Private Medical Insurance industry has long been an active user of information technology, for instance to assist with the complex task of managing insurance claims, determining conditions for cover and eligibility. In 1997 BUPA developed a ‘Decision Engine’, a series of interlinked case-bases that consult member and policy data to assist front-line call-centre decision making with regard to pretreatment authorisation. This business-critical system guarantees a consistent response to member requests with regard to what costs will be indemnified by BUPA. It also enables BUPA to provide information to members to allow them to make informed decisions and encourage specialists to carry out the most appropriate treatments. This paper looks at why the system has been a success and how work is being done to ensure that the system continues to be relevant to business needs and has the flexibility to be compatible with the developing corporate enterprise architecture.
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